Detail Claim – i-Claims

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What are you reporting today? *

How would you describe your injury *

Minor Injury (No Medical Assistance Needed)

Severe Injury (Medical Assistance Needed)

Near Fatal/Catastropic Injury (Continuous Medical Assistance Needed)

Please select the type of injury

Are you Resident of Ontario, Canada *

Yes

Sorry, we are currently not able to service outside Province of Ontario, Canada

I am reporting for *

Self

Authorised Person

Applicant Personal Information

First Name

Please provide a valid first name

Middle Name

Please provide a valid middle name

Last Name *

Please provide a valid last name

Phone *

Please provide a valid phone number

Email *

Please provide a valid email

Date of Birth *

Please select date of birth

Gender *

Male

Female

Prefer not to say

Marital Status *

Please select marital status

Number of people relying on you for financial support? *

Please select people relying on you for financial support

Identification Details

Select Document Type 1 *

Document No. *

Please enter the valid document number

Expiry Date

Please select the document expiry date

Upload Document

Please upload a valid document

Authorised Person Information

First Name

Please provide a valid first name

Middle Name

Please provide a valid middle name

Last Name *

Please provide a valid last name

Email *

Please provide a valid email

Phone *

Please provide a valid phone number

Relationship *

Please select a valid relationship

Tell Us about your Accident

Date of Accident *

Please select date of accident

Date of release from the Hospital (if Applicable)

Please select date of release from the hospital

You were a *

Driver

Passenger

Pedestrian or Cyclist

Other (Driver or Passenger – Not Insured)

Attach image as proof

Please upload a valid proof of accident

Accident Location

Hwy. No./Street Name *

Please provide a valid highway no./street name

City *

Please provide a valid city name

Province *

Please enter the Province

Accident details (Please select all that apply)

Went to collision reporting centre

Police attended

Ambulance attended

Went to the hospital

Went to doctor/nurse practitioner/other Regulated Healthcare Provider (e.g., Physiotherapist, Chiropractor etc.)

Please select at least one option in accident details

Were you charged *

Yes

This cannot be empty

Did the accident happen while you were working? *

Yes

This cannot be empty

Did the accident happen while you were travelling to and/or from work? *

Yes

This cannot be empty

If available, Please provide your Insurance Policy details. You can add this information later once you log in

Policy Number

Please provide a valid policy number

Insurance Company Name

Please provide a valid Insurance Company name

Employment Status

Please select employment details

Employment Type

Please select employment details

Above information details are: *

Self

Third Party

Do you have Extended Health Coverage Plan? *

Yes

Attach Photo of card (Optional)

Please upload a valid proof of extended health coverage plan

Legal Disclaimer

Are you currently being represented by any legal entity?

Yes

Legal Firm Name *

Please provide a valid legal firm name

Phone Number

Please provide a valid legal firm phone number

Please provide a valid email

Terms & Condition to Transfer Retainership

Sign here to Transfer Retainership

Preferred method of communication

How would you like us to reach you

Telephone

In Person

Please provide your preferred time

Morning (7am-11am)

Afternoon (11am-3pm)

Evening (3pm to 8pm)

Anytime

Do you have a family Physician?

Yes

Name *

Please enter the family physician name

Phone

Please enter the valid phone number

Please enter the valid email

Security Information

Create Password *

Please provide a valid password

Confirm Password *

Please provide a valid password

Password must be at least 8 characters long and contain at least one uppercase letter and one special character.

I understand and agree that i-Claims will collect , store and share my personal information for Insurance claims submission process. I consent and agree. Learn More

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Verify Your Email

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Thank You!

Your i-Claim Reference Number is

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Incident Reporting Disclaimer

By submitting this incident report, you acknowledge and agree to the following:

No Guarantee of Approval: Submission of this report does not guarantee that your claim will be approved. All claims are subject to review and verification.

Accuracy of Information: You certify that the information provided is true, accurate, and complete to the best of your knowledge. Providing false, misleading, or incomplete information may result in claim denial or legal consequences.

Further Documentation: Additional information or supporting documents may be required for claim processing. Failure to provide requested documentation may lead to claim rejection.

Data Use & Privacy: Your information will be used solely for claim processing and may be shared with insurers, adjusters, or third parties involved in claim evaluation as per our Privacy Policy .

Fraud Prevention: Any suspected fraudulent claims will be investigated and may be reported to relevant authorities.

What is Detail Claim?

Please use this form to complete your submission and initiate the claim process.

Upon submission, we will immediately assign your case to the appropriate legal and medical servicing teams, and notify them using your “Claim Confirmation ID.”

You will receive an email confirmation once your submission is successfully processed.

If necessary, our servicing team may contact you for additional information, based on your preferred method of communication.

Use your “Claim Confirmation ID” to log in, communicate, and receive notifications throughout the process.